The most serious threats to the health and safety of adolescents and young adults are preventable. They result from such risk-taking behaviors as fighting, substance abuse, suicide, and sexual activity rather than from illnesses. These behaviors have harmful, even deadly, consequences.

Changes in teen participation in specific risk behaviors have been well documented. What is less well known, and of growing concern, is how overall teen risk-taking has changed. In addition, information is lacking about the nuances in the behavior of adolescents who engage in more than one of these risks at a time.2 Teens who participate in multiple risks increase the chance of damaging their health.

This booklet provides a statistical portrait of teen participation in 10 of the most prevalent risk behaviors. It focuses on the overall participation in each behavior and in multiple risk-taking. The booklet presents the overall incidence and patterns of teen involvement in the following risk behaviors:

About the Surveys

Three recent surveys measure relevant health risk behaviors in teens. Together, the Youth Risk Behavior Surveys, the National Survey of Adolescent Males, and the National Longitudinal Study of Adolescent Health create a unique opportunity to describe the multiple risk-taking behaviors among diverse youth populations. They are the basis for the portrait drawn in this booklet.

The Youth Risk Behavior Surveys (YRBS). Conducted by the Centers for Disease Control and Prevention, YRBS assesses the behaviors deemed most responsible for influencing health among the nation's high school students. In 1991, 1993, 1995, and 1997, surveys were given to a nationally representative sample of students in grades 9 through 12. Students completed self-administered questionnaires in the classroom during a regular class period. Overall response rates in 1991, 1993, 1995, and 1997 were 68 percent, 70 percent, 60 percent, and 69 percent, respectively; the sample sizes were 12,272 students, 16,296 students, 10,904 students, and 16,262 students, respectively. More information about YRBS and access to data is available at www.cdc.gov/nccdphp/dash.

The National Longitudinal Study of Adolescent Health (Add Health). Add Health is a school-based study of the health-related behaviors of adolescents in the United States. Interviews were conducted in two stages. In the first stage, students in grades 7 through 12 attending 145 schools answered brief questionnaires in their classrooms. In the second stage, in-home interviews were conducted with a subset of students between April and December of 1995. Data for this study came from the 12,105 students participating in both stages of the survey who are representative of adolescents in grades 7 through 12 during the 1994--95 school year. More information about Add Health and access to data is available at www.cpc.unc.edu/addhealth.

The 1995 National Survey of Adolescent Males (NSAM). NSAM is a household survey of a nationally representative sample of 1,729 boys ages 15 through 19. It was designed primarily to examine behavorial aspects of young men's sexual and reproductive behaviors and includes extensive measures of nonsexual risk-taking. The sample is nationally representative of both students and nonstudents. Face-to-face interviews were conducted by trained interviewers in the respondents' homes. The response rate was 75 percent. More information about NSAM and access to data is available at www.socio.com.

A Word about Interviewing Techniques. Prior studies of health risk behaviors among adolescents have been hampered by concerns about the honesty of self-reports for behaviors that are highly sensitive and potentially illegal. To address this concern, both NSAM and Add Health use new computer-assisted interviewing technology to enhance the quality of self-reported data. In these studies, adolescents answer sensitive questions directly on laptop computers instead of using standard paper-and-pencil, self-administered questionnaires. Researchers using NSAM found that teen males were significantly more likely to report participation in many health risk behaviors using the computer rather than the paper self-administered questionnaires.3 For example, male teens were two times as likely to report daily marijuana use in the past year on the computer questionnaire as compared with the paper-and-pencil version.

Regular alcohol use

Regular binge drinking

Regular tobacco use

Marijuana use

Other illegal drug use

Fighting

Weapon carrying

Suicidal thoughts

Suicide attempts

Risky sexual activity

The complex picture that emerges alleviates some traditional concerns, while raising new ones. Teens' overall involvement in risk-taking has declined during the past decade (except among Hispanics), with fewer teens engaging in multiple risk behaviors. But multiple-risk teens remain an important group, responsible for most adolescent risk-taking. However, almost all risk-takers also engage in positive behaviors; they participate in desirable family, school, and community activities. These positive connections offer untapped opportunities to help teens lead healthier lives.

The booklet covers three aspects of risk behaviors among teens: (1) changes in risk-taking among high school students over the past decade; (2) incidence and patterns of multiple risk-taking among teens; and (3) extent and pattern of involvement of multiple risk-takers in school clubs, teen sports, religious services or youth groups, the workplace, and the health care system.

The data and discussions are based on analyses of three recent national surveys: the Youth Risk Behavior Surveys (YRBS), the National Survey of Adolescent Males (NSAM), and the National Longitudinal Study of Adolescent Health (Add Health). The research was conducted for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Focusing on trends and patterns in overall risk-taking and multiple risk-taking, the booklet reports that:

Overall risk-taking among high school students declined during the 1990s. Between 1991 and 1997, there was a sizable increase in the share of students who did not participate in any of the 10 risk behaviors and a sizable decrease in the proportion of students who engaged in multiple risk behaviors. Despite this, the share of highest-risk studentsthose participating in five or more risk behaviors-remained stable. Of note, Hispanic students did not report the same shift toward less risk-taking.

Most risks are taken by multiple-risk students. The overall prevalence of a specific risk behavior among teenagers is due primarily to the behavior of multiple-risk students, since the majority of students involved in any given behavior also were engaging in other risk behaviors. For example, among the 12 percent of students reporting regular tobacco use, 85 percent were multiple risk-takers.

Nearly all teens, even those engaging in multiple risk behaviors, participate in positive behaviors. Ninety-two percent of students engage in at least one positive behavior, such as earning good grades, participating in extracurricular activities, spending time with parents, or being involved in a religious institution. Most out-of-school boys also were involved in appropriate positive behaviors, although less so than their in-school peers. While multiple-risk teens engage in positive behaviors, participation in positive behaviors declines with increased risk-taking.

Multiple-risk adolescents have many points of contact beyond home and the classroom. The assumption that risk-taking teens are socially disconnected is challenged by new findings that map their participation in a wide range of settings, such as faith-based institutions, the workplace, health care, and the criminal justice system. Their involvement in settings beyond the home and the classroom, especially for out-of-school adolescents, offers opportunities for health intervention to reduce risk-taking.

Based on these trends and patterns in teen risk-taking, parents, educators, and policymakers should:

Support positive behaviors of non-risk-taking teens. Declines in risk-taking mean that the share of students taking no risks has increased. These teens need support and expanded opportunities to continue making responsible and healthy decisions as they mature.

Target efforts to reduce specific risk behaviors toward multiple-risk students. Recent public health and policy efforts to reduce the prevalence of key risk behaviors, such as smoking or violence, cannot address these behaviors in isolation from other risk-taking.

Encourage positive behaviors of risk-taking teens, such as time spent on extracurricular or faith-based activities. These behaviors connect students to adults and social institutions and offer opportunities to prevent risk-taking among some students or reduce risk-taking among others.

Expand efforts to reach multiple-risk adolescents in nontraditional settings. Teen participation in settings such as the workplace, the criminal justice system, and faith-based institutions offers innovative opportunities for health services and education programs and the development of personal relationships with positive adult role models that can reduce risk-taking.

Take new steps to reduce risk-taking among Hispanic students. Further research is needed to better understand both risk-taking and adolescent development of this growing group of teens. Programs that are responsive and sensitive to the current ethnic and social diversity of Hispanic adolescents need to be developed and implemented.

Measuring Health Risk Behaviors

Health risk behaviors are voluntary behaviors that threaten the well-being of teens and limit their potential for achieving responsible adulthood.4 Such behaviors also are commonly referred to as "problem behaviors."5 Risk-taking is distinguishable from risk outcomesthe consequences of the behavior. For example, unprotected sexual intercourse is a risk behavior and is included in this analysis, while teenage pregnancy is a risk outcome and is not examined here.

The definitions of the risk behaviors employed here address regular or established patterns of risk-taking, not just exploratory behavior, by incorporating indicators of recent and frequent participation. For example, "regular tobacco use" refers to the daily use of cigarettes or chewing tobacco during the past 30 daysnot infrequent experimentation.6

Three recent national surveysthe Youth Risk Behavior Surveys (YRBS), the National Survey of Adolescent Males (NSAM), and the National Longitudinal Survey of Adolescent Health (Add Health)provide data on the 10 risk behaviors.

A number of qualifications should guide interpretation of the information provided in this portrait. First, common definitions across the three surveys were applied whenever possible. However, differences in the design and administration of these surveys create some lack of comparability. For example, definitions of sexual risk-taking differ. In Add Health and NSAM, it means participation in sexual intercourse without contraception. A comparable measure in YRBS is not possible, since it refers to ever engaging in sexual intercourse and thus involves more students. Accordingly, prevalence of risk-taking is examined within each survey, and no attempt is made to create comparisons among surveys.

Second, many of the behaviors are measured with reference to different time periods. Questions about substance use and weapon carrying, for instance, refer to the 30 days prior to the survey; those about suicidal thoughts, suicide attempts, and fighting refer to the year before the survey.

Third, the data presented are descriptive in nature. They describe associations only; causal inferences should not be drawn. Establishing that one behavior occurs with another does not mean that one causes the other.

Fourth, while the behaviors examined are of critical public concern, they do not make an exhaustive list of adolescent health risks.7 Other studies have explored additional types of risk-taking, such as dangerous driving, eating disorders, and criminal activity.8 Conclusions from this study do not necessarily extend to these other types of behaviors.

Finally, both the YRBS and Add Health studies only include students and cannot be used to generalize to all adolescents, including those currently out of school. The surveys likely underestimate the prevalence of risk behaviors among all teenagers, since those who drop out of school are at higher risk of engaging in health risk behaviors.9 Estimates of risk behaviors among older adolescents will be particularly affected, since they are more likely to drop out or to have completed school.

To address this limitation of the other data sources, the 1995 NSAM was used to examine risk-taking among adolescent males ages 15 through 19, both in school and out of school. The out-of-school population includes high school dropouts and those who have completed high school but are not currently enrolled in postsecondary education. Even so, it is important to note that since NSAM interviews male adolescents living in households, there is no information about teens with more tenuous connections to institutions, for example, homeless or runaway teens.10

2. There is also concern about adolescents' participation in more than one risk behavior at a single point in time, such as drinking immediately prior to sexual intercourse. (See, for example, Halpern-Felsher, B.L., Millstein, S.G., and Ellen, J.M. 1996. "Relationship of Alcohol Use and Risky Sexual Behavior: A Review and Analysis of Findings." Society for Adolescent Medicine 19: 331-36.)

6. This is similar to the measure of cigarette smoking employed in the national indicators of child well-being. U.S. Department of Health and Human Services (DHHS). Office of the Assistant Secretary for Planning and Evaluation. 1998. Trends in the Well-Being of America's Children and Youth. Washington, DC: DHHS.

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